Date of Application

Name (Last, First, Middle)

Address

City

State

Zip

Phone/Cell

Position applying for

Desired pay

Work availability
Full-timePart-timeTemporary

Hour availabilty
1st shift (8 am - 4 pm)2nd shift (4 pm - 12 am)3rd shift (12 am - 8 am)

Were you referred by a current employee?
YesNo

If yes, employee's name

Are you over 18 years of age?
YesNo

Were you previously employed by us?
YesNo

If yes, give dates and positions/Dates

Are you legally authorized for employment in the United States?
(If offered employment you will be required to provide documentation to verify eligibility.)
YesNo

Have you ever been fired or asked to resign from a job?
YesNo

If yes, please explain:

Have you ever been convicted of a major crime (felony) in the past?
(A conviction will not automatically disqualify an applicant from a particular job.)
YesNo

If yes, please give the conviction date, location, and the nature of the offense:

Education

High School Name and Address

Did you graduate?
YesNo

College Name and Address

College Course or Major

Did you graduate?
YesNo

Degree

Business or Trade School Name

Business or Trade School Course or Major

Did you graduate?
YesNo

Degree

Other schooling Name

Other schooling Course or Major

Did you graduate?
YesNo

Other schooling degree

Special Skills, Qualifications, Considerations

Summarize special skills and qualifications, volunteer activities, military experience, employment or other activities related to the job you are seeking

References
List three professional or personal references (not relatives).

Name

Occupation

Years known

Telephone

Name

Occupation

Years known

Telephone

Name

Occupation

Years known

Telephone

Employment History
List present and past employment, beginning with your most recent.

Name and address of company:

Supervisor

Telephone

Duites

Start Date

End Date

Starting Wage

Ending Wage

Reason for Leaving

May we contact for reference?
YesNo

Name and address of company:

Supervisor

Telephone

Duites

Start Date

End Date

Starting Wage

Ending Wage

Reason for Leaving

May we contact for reference?
YesNo

Name and address of company:

Supervisor

Telephone

Duites

Start Date

End Date

Starting Wage

Ending Wage

Reason for Leaving

May we contact for reference?
YesNo

Name and address of company:

Supervisor

Telephone

Duites

Start Date

End Date

Starting Wage

Ending Wage

Reason for Leaving

May we contact for reference?
YesNo

Applicant Statement
I hereby certify that all information provided by me in this application (or any other accompanying or required documents) is correct, accurate and complete to the best of my knowledge. I authorize Midstates Group to verify the accuracy and information provided. I release all parties involved from any and all liability for any and all damage that may result from providing such information. I understand that, if employed, falsified statements of any kind or omissions of facts called for on this application shall be considered sufficient basis for dismissal.

I understand that submission of an application does not guarantee employment. If hired, I will be employed at will; I understand that this means that either I or the employer is free to terminate the employment relationship at any time with or without cause or prior notice. I understand that no representative of the company, other than the CEO, has any authority to enter into an agreement for employment for any specified period of time or, in any way, to modify the at-will nature of the employment relationship.

I understand that if I am offered employment, it could result in a pre-employment drug screening and background check at the expense of Midstates Group and that this is a condition of employment.

I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies, rules and regulations of employment of Midstates Group.

By checking below I acknowledge that I have read, understood and agree to the above statements.

DO NOT CHECK UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

This application is valid for ninety (90) days from the date submitted. If you would like to be considered for job openings more than ninety (90) days from the date signed, please submit a new application.